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Chapter 1 Health Care Benefits

Federal Benefits for Veterans, Dependents and Survivors

Federal Benefits for Veterans, Dependents and Survivors

Quick Nav

For additional information on VA health care, visit: www.va.gov/health as well as VHA’s 2015 Health Care Benefits Overview – a guide designed to provide Veterans and their families with the information they need to understand VA’s health care system.

Basic Eligibility: A person who served in the active military, naval, or air service and who was discharged or released under conditions other than dishonorable may qualify for VA health care benefits including qualifying Reserve and National Guard members.

Minimum Duty Requirements: Veterans who enlisted after Sept. 7, 1980, or who entered active duty after Oct. 16, 1981, must have served 24 continuous months or the full period for which they were called to active duty in order to be eligible. This minimum duty requirement may not apply to Veterans discharged for hardship, early out or a disability incurred or aggravated in the line of duty.

Enrollment: For most Veterans, entry into the VA health care system begins by applying for enrollment. Veterans can now apply and submit their application (VA Form 1010EZ), online at http://www.va.gov/vaforms/form_detail.asp?formno=10ez. If assistance is needed for the online enrollment form, an online chat representative is available to answer questions Monday – Friday, between 8 a.m. and 8 p.m. EST. Veterans can also enroll by calling 1-877-222-8387, Monday through Friday, 8 a.m. to 8 p.m. EST, or at any VA health care facility or VA regional office. Once enrolled, Veterans can receive health care at VA health care facilities anywhere in the country.

The following four categories of Veterans are not required to enroll, but are urged to do so to permit better planning of health resources:

Veterans with a service-connected disability of 50 percent or more.

Veterans seeking care for a disability the military determined was incurred or aggravated in the line of duty, but which VA has not yet rated, within 12 months of discharge.

Priority Groups: During enrollment, each Veteran is assigned to a priority group. VA uses priority groups to balance demand for VA health care enrollment with resources. Changes in available resources may reduce the number of priority groups VA can enroll. If this occurs, VA will publicize the changes and notify affected enrollees. A description of priority groups follows:

Group 1:

Veterans with service-connected disabilities rated 50 percent or more and/or Veterans determined by VA to be unemployable due to service-connected conditions.

Group 2:

Veterans with service-connected disabilities rated 30 or 40 percent.

Group 3:

Veterans who are former prisoners of war (POWs).

Veterans awarded the Purple Heart medal.

Veterans awarded the Medal of Honor.

Veterans whose discharge was for a disability incurred or aggravated in the line of duty.

Veterans exposed to ionizing radiation during atmospheric testing or during the occupation of Hiroshima and Nagasaki. Project 112/SHAD participants.

Veterans who served in the Republic of Vietnam between Jan. 9, 1962 and May 7, 1975.

Veterans who served in the Southwest Asia theater of operations from Aug. 2, 1990, through Nov. 11, 1998.

Veterans who served in a theater of combat operations after Nov. 11, 1998, as follows:

Veterans discharged from active duty on or after Jan. 28, 2003, for five years post discharge;

Veterans who served on active duty at Camp Lejeune, N.C., for no fewer than 30 days beginning Jan. 1, 1957, and ending Dec. 31, 1987.

Group 7:

Veterans with incomes below the geographic means test income thresholds and who agree to pay the applicable copayment.

Group 8:

Veterans with gross household incomes above VA national income threshold and the geographically-adjusted income threshold for their resident location and who agree to pay copayments. Veterans eligible for enrollment: Noncompensable 0-percent service-connected:

Subpriority a: Enrolled as of Jan. 16, 2003, and who have remained enrolled since that date and/or placed in this subpriority due to changed eligibility status.

Subpriority b: Enrolled on or after June 15, 2009, whose income exceeds the current VA national income thresholds or VA national geographic income thresholds by 10 percent or less Veterans eligible for enrollment: nonservice-connected and

Subpriority c: Enrolled as of Jan. 16, 2003, and who remained enrolled since that date and/ or placed in this subpriority due to changed eligibility status

Subpriority d: Enrolled on or after June 15, 2009 whose income exceeds the current VA national income thresholds or VA national geographic income thresholds by 10 percent or less Veterans NOT eligible for enrollment: Veterans not meeting the criteria above:

Veterans Choice Program

As directed by the Veterans Access, Choice and Accountability Act of 2014, VA implemented the Veterans Choice Program, which will operate for 3 years or until the Fund is exhausted. The program allows certain eligible Veterans to elect to receive care from non-VA health care providers if they cannot receive VA care within 30 days or live more than 40 miles from a VA facility or face excessive travel burdens.

VA will also extend the Assisted Living Pilot Program for Veterans with Traumatic Brain Injury for 3 years, through October 6, 2017. This program assesses the effectiveness of providing assisted living services to eligible Veterans with traumatic brain injuries to “enhance the rehabilitation, quality of life, and community integration of such Veterans.”

Under the Act, Veterans can receive counseling and appropriate care and services required to overcome psychological trauma resulting from military sexual trauma (MST) that occurred while the Veteran was serving on inactive duty training (such as drill weekends for members of the Reserves and National Guard). Such benefits are provided at no cost to the Veteran.

The Choice Act also authorizes VA, in consultation with the Department of Defense (DoD), to provide MST-related care and services to members of the Armed Forces on active duty (including members of the National Guard and Reserves) without the need for a referral from a TRICARE provider or a military treatment facility. VA is working with DoD on implementation of this benefit.

Maternity care is covered in the Medical Benefits package. Women Veterans can receive maternity care from an OB/GYN, family practitioner, or certified nurse midwife who provides pregnancy care. VA covers the costs of care for newborn children of women Veterans for seven days after birth. Infertility evaluation and limited treatments are also available.

Women Veterans Program Managers are available at all VA facilities to assist women Veterans in their health care and benefits. For more information, visit http://www.womenshealth.va.gov/.

Lesbian Gay Bisexual and Transgender (LGBT) Veterans: LGBT Veterans are eligible for the same VA benefits as any other Veteran and will be treated in a welcoming environment. Transgender Veterans will be treated based upon their self-identified gender, including room assignments in residential and inpatient settings. Same-Sex Couples: VA launched a new website to inform Veterans and beneficiaries of the recent changes in the law and procedures involving same-sex marriages. Veterans can learn more about VA’s guidance regarding same-sex marriages at www.va.gov/opa/marriage.

Military Sexual Trauma: Military sexual trauma (MST) is the term that VA uses to refer to sexual assault or repeated, threatening sexual harassment that occurred while a Veteran was serving on active duty (or active duty for training if the service was in the National Guard or Reserve). VA health care professionals provide counseling and treatment to help Veterans overcome health issues related to MST. Veterans who are not otherwise eligible for VA health care may still receive these services. For additional information, visit: http://www.mentalhealth.va.gov/msthome.asp.

Presumptive Eligibility for Psychosis and Other Mental Illness: Certain Veterans who experienced psychosis within a specified timeframe are to have their psychosis presumed to be service-connected for purposes of VA medical benefits.

Psychosis: Eligibility for treatment of psychosis, and such condition is exempted from copayments for any Veteran who served in the United States active duty military, naval, or air service and developed such psychosis within two years after discharge or release from the active military duty, naval or air service; and before the following date associated with the war or conflict in which the Veteran served:

Mental Illness (other than Psychosis): Eligibility for benefits is established for treatment of an active mental illness (other than psychosis), and such condition is exempted from copayments for any Veteran of the Persian Gulf War who developed such mental illness:

a. Within two years after discharge or release from the active duty military, naval, or air service; and

b. Before the end of the two-year period beginning on the last day of the Persian Gulf War (end date not yet determined).

Veterans who are enrolled in VA health care don’t need to take additional steps to meet the health care law coverage standards.

The health care law does not change VA health benefits or Veterans’ out-of-pocket costs.

Veterans who are not enrolled in VA health care can apply at any time.

Veterans whose income does not exceed the maximum. annual VA pension rate.

Veterans in certain emergency situations.

Veterans whose medical condition requires a special mode of transportation and travel is pre-authorized. (Advanced authorization is not required in an emergency, and a delay would be hazardous to life or health).

Certain non-veterans when related to care of a Veteran (caregivers, attendants, donors and other claimants subject to current regulatory guidelines)

OEF/OIF/OND Care Management: Each VA medical center has an Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Care Management team in place to coordinate patient care activities and ensure that Servicemembers and Veterans are receiving patient-centered, integrated care and benefits. More information for connecting with OEF/OIF/OND Care Management teams can be found at http://www.oefoif.va.gov.

Key Information for Veterans about the Affordable Care Act /Health Care Law

For additional information about VA and the health care law, visit www.va.gov/aca or call 1-877-222-VETS (8387).

Financial Assessment: Most Veterans not receiving VA disability compensation or pension payments must provide a financial assessment, also known as a means test, upon initial application to determine whether they are below VA income thresholds. VA is currently not enrolling new applicants who decline to provide financial information unless they have a special eligibility factor exempting them from disclosure. VA’s income thresholds are located at http://nationalincomelimits.vaftl.us/.

As of 2014, VA no longer requires enrolled non-service connected and 0-percent non-compensable service connected Veterans to provide their financial information annually. A means test will continue to be collected from Veterans at the time of application for enrollment. In lieu of the annual financial reporting, VA will confirm the Veteran’s financial information using information obtained from the Internal Revenue Service and Social Security Administration.

Medical Services and Medication Copayments: Some Veterans are required to make copayments (copays) to receive VA health care and/or medications.

Inpatient Care: Priority Group 7 and certain other Veterans are responsible for paying 20 percent of VA’s inpatient copay, which totals $243.20 for the first 90 days of inpatient hospital care during any 365-day period. For each additional 90-day period, the charge is $121.60. In addition, there is a $2 per diem charge. Copay amounts may change on an annual basis.

Priority Group 8 and certain other Veterans are responsible for VA’s inpatient copay, which totals $1,216 for the first 90 days of care during any 365-day period. For each additional 90-day period, the charge is $608. In addition, there is a $10 per diem charge. Copay amounts may change on an annual basis.

Extended Care Services: Veterans may be subject to a copay for extended care services. The copay amount is based on the Veteran’s available resources and is determined by a calculation using the financial information from VA Form 10-10EC, Application for Extended Care Services. The copay can range from $0 to a maximum copay amount of $97 a day.

Outpatient Care: While many Veterans qualify for free health care services based on a VA compensable service-connected condition or other qualifying factor, most Veterans are asked to provide a financial assessment, to determine if they qualify for free services. Veterans whose income exceeds the established VA Income Thresholds, as well as those who choose not to complete the financial assessment, must agree to pay required copays to become eligible for VA health care services.

NOTE: The copay amount is limited to a single charge per visit regardless of the number of health care providers seen in a single day. The copay amount is based on the highest level of clinical service received. Certain services are not charged a copay. Copays do not apply to publicly announced VA health fairs or outpatient visits solely for preventive screening and/or vaccinations.

Medication Copays: While many Veterans are exempt for medication copays, nonservice-connected Veterans in Priority Groups 7 and 8 are charged $9 for each 30-day or less supply of medication provided on an outpatient basis for the treatment of a nonservice-connected condition. Veterans enrolled in Priority Groups 2 through 6 are charged $8 for each 30-day or less supply of medication; the maximum copay for medications that will be charged in calendar year 2013 is $960 for nonservice-connected medications.

NOTE: Copays apply to prescription and over-the-counter medications, such as aspirin, cough syrup or vitamins dispensed by a VA pharmacy. Copays are not charged for medical supplies, such as syringes or alcohol wipes. Copays do not apply to condoms. Health Savings Accounts: (HSAs) can be utilized to make VA copayments. HSAs are usually linked to High Deductible Health Plans (HDHPs).

Reimbursement of Travel Costs: Eligible Veterans and non-veterans may be provided mileage reimbursement or, when medically indicated, special mode transport (e.g., wheelchair van, ambulance), when travel is in relation to VA medical care. Mileage reimbursement is 41.5 cents per mile and is subject to a deductible of $3 for each one-way trip and $6 for a round trip; with a maximum deductible of $18 or the amount after six one-way trips (whichever occurs first) per calendar month. The deductible may be waived when travel is; in relation to a VA compensation or pension examination; by a special mode of transportation; by an eligible non-veteran; or will cause a severe financial hardship, as defined by current regulatory guidelines.

Veteran Health Registries: Certain Veterans can participate in a VA health registry and receive free evaluations. VA maintains health registries to provide special health evaluations and health-related information. To participate, contact the Environmental Health Coordinator at the nearest VA health care facility or visit www.publichealth.va.gov/exposures to see a directory which lists Environmental Health Coordinators by state and U.S. territory. Veterans should be aware that a health registry evaluation is not a disability compensation exam. A registry evaluation does not start a claim for compensation and is not required for any VA benefits.

Gulf War Registry: For Veterans who served on active military duty in Southwest Asia during the Gulf War, which began in 1990 and continues to the present, and includes Operation Iraqi Freedom (OIF) and Operation New Dawn (OND).

Embedded Fragment Registry: OEF, OIF, and OND Veterans who have or likely have an embedded fragment as the result of an injury they received while serving in an area of conflict.

Agent Orange Registry: Agent Orange is an herbicide that the U.S. military used between 1962 and 1971, during the Vietnam War to remove jungle that provided enemy cover. Veterans serving in Vietnam were possibly exposed to Agent Orange or its dioxin contaminant. Veterans eligible for this registry evaluation are those who served on the ground in Vietnam between Jan. 9, 1962, and May 7, 1975, regardless of the length of service; this includes Veterans who served aboard boats that operated on inland waterways (“Brown Water Navy”) or who made brief visits ashore. Information is also available through VA’s Special Issues Helpline at 1-800-749-8387.

Ionizing Radiation Registry: For Veterans who have received nasopharyngeal (nose and throat) radium irradiation treatments while on active duty and Veterans possibly exposed to radiation.Airborne Hazards and Open Burn Pit Registry: Unlike other registries, when Veterans complete the online Airborne Hazards and Open Burn Pit Registry self-assessment questionnaire, they are in the registry. No in-person medical evaluation is required to become registered. Veterans not already enrolled in VA health care should contact an Environmental Health Coordinator at a nearby VA facility by visiting the following link: (http://www.publichealth.va.gov/exposures/coordinators.asp) or calling 1-877-222-8387.

Vet Center Readjustment Counseling Services: VA provides readjustment counseling services, to include direct counseling, outreach, and referral, through 300 community-based Vet Centers located in all 50 states, the District of Columbia, Guam, Puerto Rico, and American Samoa. Vet Center counselors provide individual, group, marriage, and family readjustment counseling to those individuals that have served in combat zones or areas of hostilities to assist them in making a successful transition from military to civilian life; to include treatment for posttraumatic stress disorder (PTSD), and help with any other military-related problems that affect functioning within the family, work, school or other areas of everyday life. Other psycho-social services include outreach, education, medical referral, homeless Veteran services, employment, VA benefit referral, and the brokering of non-VA services.

Bereavement Counseling related to Servicemembers: Bereavement counseling is available through VA’s Vet Centers to all immediate family members (including spouses, children, parents, and siblings) of Servicemembers who die while serving on active service. Vet Center bereavement services for surviving family members of Servicemembers may be accessed by calling (202) 461-6530. For additional information, contact the nearest Vet Center, listed in the back of this book, or visit http://www.vetcenter.va.gov/.

Vet Center Combat Call Center: (1-877-WAR-VETS) is an around the clock confidential call center where combat Veterans and their families can call to talk about their military experience or any other issue they are facing in their readjustment to civilian life. The staff is comprised of combat Veterans from several eras as well as family members of combat Veterans.

Home Improvements and Structural Alterations: VA provides up to $6,800 lifetime benefits for service-connected Veterans/Servicemembers and up to $2,000 lifetime benefits for nonservice-connected Veterans to make home improvements and/or structural changes necessary for the continuation of treatment or for disability access to the Veterans/Servicemembers home and essential lavatory and sanitary facilities. For application information, contact the Prosthetic Representative at the nearest VA medical center.

Services for Blind and Visually Impaired Veterans: Severely disabled blind Veterans may be eligible for case management services at a VA medical center and for admission to an inpatient or outpatient VA blind or vision rehabilitation program.

Veterans Crisis Line: Veterans experiencing emotional distress/crisis, or who need to talk to a trained mental health professional, may call the Veterans Crisis Line, 1-800-273-TALK (8255). The hotline is available 24 hours a day, seven days a week. When callers press “1,” they are immediately connected with a qualified and caring provider who can help.

Chat feature: Veterans Chat is located at www.Veterancrisisline.net by clicking on the Veterans chat tab on the right side of the webpage.

The PTSD Coach is a mobile application that provides information about PTSD, self-assessment and symptom management tools and information about how to connect with resources that are available for those who might be dealing with post-trauma effects. The PTSD Coach is available as a free download for iPhone or Android devices.

Outpatient Dental Treatment: Dental benefits are provided by VA according to law. In some instances, VA is authorized to provide extensive dental care, while in other cases treatment may be limited by law. For more information about eligibility for VA medical and dental benefits, contact VA at 1-877-222-8387, or http://www.va.gov/healthbenefits.

Vocational and Work Assistance Programs

VHA Therapeutic & Supported Employment Services (TSES) Programs: These programs are designed to assist Veterans to live and work as independently as possible in their respective communities. Participation in TSES vocational services cannot be used to deny or discontinue VA disability benefits. Payments received from Compensated Work Therapy Sheltered Workshop and Transitional Work and Incentive Therapy cannot be used to deny or discontinue SSI and/or SSDI payments and they are not subject to IRS taxes.

Long-term Services: VA provides institution based services (nursing home level of care) to Veterans through three national programs: VA owned and operated Community Living Centers (CLC), State Veterans’ Homes owned and operated by the states, and the community nursing home program. Each program has admission and eligibility criteria specific to the program. VA is obligated to pay the full cost of nursing home services for enrolled Veterans who need nursing home care for a service-connected disability, or Veterans or who have a 70 percent or greater service-connected disability and Veterans with a rating of total disability based on individual un-employability. VA provided nursing home care for all other Veterans is based on available resources.

Emergency Medical Care in U.S. Non-VA Facilities: In the case of medical emergencies, VA may reimburse or pay for emergency non-VA medical care not previously authorized that is provided to certain eligible Veterans when VA or other federal facilities are not feasibly available. This benefit may be dependent upon other conditions, such as notification to VA, the nature of treatment sought, the status of the Veteran, the presence of other health care insurance, and third party liability. Because there are different regulatory requirements that may affect VA payment and Veteran liability for the cost of care, it is very important that the nearest VA medical facility to where emergency services are furnished be notified as soon as possible after emergency treatment is sought.

Foreign Medical Program: VA may authorize reimbursement for medical services for service-connected disabilities or any disability associated with and found to be aggravating a service-connected disability for those Veterans living or traveling outside the United States. Veterans calling from within the Philippines may contact the VA office in Pasay City at 1-800-1888-8782. If calling from outside of the Philippines, the number is 011-632-318-8387. Veterans may also register by email at IRIS.va.gov. All other Veterans living or planning to travel outside the U.S. should register with the Foreign Medical Program, P.O. Box 469061, Denver, CO 80246-9061, USA; telephone 303-331-7590. For information, visit: http://www.va.gov/hac/forbeneficiaries/fmp/fmp.asp.

Caregiver Programs and Services: VA has long supported family caregivers as vital partners in providing care worthy of the sacrifices of America’s Veterans and Servicemembers. Each VA medical center has a Caregiver Support Program coordinated by a Caregiver Support Coordinator (CSC). The CSC coordinates caregiver activities and serves as a resource expert for Veterans, their families and VA providers.